Case Report The First Evidence of Lyme Neuroborreliosis in …downloads.hindawi.com/journals/criid/2014/231969.pdf · Case Report The First Evidence of Lyme Neuroborreliosis in Southern

Case ReportThe First Evidence of Lyme Neuroborreliosis inSouthern Bosnia and Herzegovina

Jurica Arapovic,1,2 Sinisa Skocibusic,1,2 Svjetlana Grgic,1,2 and Jadranka Nikolic1,2

1Clinic for Infectious Diseases, University Hospital Mostar, Kralja Tvrtka bb, 88000 Mostar, Bosnia and Herzegovina2School of Medicine, University of Mostar, Bijeli Brijeg bb, 88000 Mostar, Bosnia and Herzegovina

Correspondence should be addressed to Jurica Arapovic; [email protected]

Received 27 June 2014; Accepted 3 December 2014; Published 15 December 2014

Academic Editor: Sinesio Talhari

Copyright © 2014 Jurica Arapovic et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Lyme borreliosis (LB) is caused by the spirochete Borrelia burgdorferi, which is transmitted to humans by ticks of the Ixodesricinus complex. It is manifested by a variety of clinical symptoms and affects skin, joints, heart, and nervous system. Neurologicalmanifestations are predictable and usually include meningoencephalitis, facial palsy, or radiculopathy. Recently, a dramatic rise inthe number of diagnosed cases of LB has been observed on the global level. Here we show the first case of Lyme neuroborreliosis insouthern Bosnia andHerzegovina, which was first presented by erythema chronicummigrans. Unfortunately, it was not recognizedor well treated at the primary care medicine. After eight weeks, the patient experienced headache, right facial palsy, and lumbarradiculopathy. After the clinical examination, the neurologist suspected meningoencephalitis and the patient was directed to theClinic for Infectious Disease of the University Hospital Mostar, where he was admitted. The successful antimicrobial treatmentwith the 21-day course of ceftriaxone was followed by normalization of neurological status, and then he was discharged from thehospital. This case report represents an alert to all physicians to be aware that LB is present in all parts of Bosnia and Herzegovina,as well as in the neighboring regions.

1. Introduction

Lyme disease or Lyme borreliosis (LB) is caused by thespirochete Borrelia burgdorferi sensu lato group with itshuman pathogenic species B. burgdorferi sensu stricto, B.garinii, and B. afzelii, which are transmitted by ticks ofthe species Ixodes [1, 2]. LB is manifested by a variety ofclinical symptoms with occurrence of primary infection. It isamultiorganic disease affecting skin, joints, heart, and centralnervous system, causing many neurological manifestationsusually characterized by meningoencephalitis, facial palsy, orradiculopathy [2, 3]. LB can be divided into three stages. Ofepidemiological importance is that the first stage of illnessusually begins in the summer or spring, with presented ery-theproteinorraahiama chronicum migrans at the site of thetick bite.The second stage of illness occurswithin several daysto weeks later, when the pathogen may spread to differentparts of the body like the nervous system, heart, or joints.The third stage of illness may be developed up to several

years after primary infection. This stage is characterized bypersistent disease affecting the joints, nervous system, skin,and many other organs [1]. Of importance is that all thesestages can be effectively treated with antimicrobial regiments[4].

Up to 80% of patients develop erythema chronicummigrans at the site of the tick bite [5]. However, in theabsence of erythema chronicum migrans, physicians oftenhave difficulties to diagnose LB [6]. The final diagnosisof LB is based on specific clinical symptoms that shouldbe confirmed by serologic tests including ELISA, or morespecifically, tests like Western blot [7].

From the epidemiological point of view, it is important toemphasize that, in many European countries and the UnitedStates, a dramatic increase of diagnosed patients with LB wasobserved [8]. Also, many previously unnoticed regions arenow affected with this pathogen [3]. So far in our broaderregion, including Croatia and Serbia, it has been speculatedthat the occurrence of LB was generally restricted to Serbia,

Hindawi Publishing CorporationCase Reports in Infectious DiseasesVolume 2014, Article ID 231969, 3 pageshttp://dx.doi.org/10.1155/2014/231969

2 Case Reports in Infectious Diseases

northern Croatia, and northern Bosnia and Herzegovina [9–12].

2. Case Description

Two months prior to admittance to the Clinic for InfectiousDisease of the University Hospital Mostar, a 45-year old malewas bitten by a tick in the area of right upper arm. He residedin a forest near the city ofMostar, which is located in southernBosnia and Herzegovina. Several days later, a ring-shapederythema appeared around the bitten area. The erythemawas getting bigger and bigger, without affecting the otherparts of the body. He visited a family medicine specialistat the Community Health Centre of Mostar, who treatedhim with cephalexin (1 g twice daily) for one week. Eightweeks later, the patient reported headache and neck pain.A day later, the pain went down to the regions of the backand legs. He again visited the Community Health Centre ofMostar, and the physician gave him nonsteroidal and opioidpain relievers. Despite strong analgesics, the symptoms didnot decline. Then he visited the Clinic for Neurology of theUniversity Hospital Mostar. A neurologist advised him tostart the physical therapy and continue analgesic treatment.In the meantime, the patient was subjected to computedtomography (CT) of the lumbar regionwithout any patholog-ical finding. A few days later he presented with the right facialnerve palsy and interscapular pain, whereas the headachewas still present. After the second neurological examination,the patient was directed to the Clinic for Infectious Diseaseof the University Hospital Mostar, where further treatmentwas initiated. All this time he had no fever. At admission tothe hospital the patient had blood pressure of 140/80mmHg.All routine blood biochemical findings in sera were normal.Lumbar puncture was administrated and cerebrospinal fluid(CSF) analysis showed pleocytosis: 139 cells in 3 visionfields with 92% of lymphocytes, positive Pandy reaction,and elevated CSF total proteins 1.04 g/L (normal range is0.15–0.45 g/L). An indirect immunofluorescence test for B.burgdorferi IgG antibodies in CSF was positive at ratio 1 : 256(normal range < 1 : 2). The ELISA test for B. burgdorferishowed a high titer of IgM antibodies: 59.11 RU/mL, as well asIgG antibodies: 146.82 RU/mL (a result is considered positivewhen antibody titers exceed 22 RU/mL). Magnet resonanceimaging (MRI) of the brain showed no abnormalities. Takingall together, these results suggested Lyme neuroborreliosis,which was manifested by facial palsy and radiculopathy. Thetwenty-one-day therapy with ceftriaxone (2 g once daily)was administered, supported by prednisone and vitamin Bpreparations. Also, the patient was daily rehabilitated by aphysiotherapist and recovered during hospitalization. He wasdischarged with completely normal neurological status. Hewas followed up for 12 months, with completely normalneurological status and laboratory blood findings.

3. Discussion

In this paper we described the first case of Lyme neurobor-reliosis in southern Bosnia and Herzegovina. A 45-year-old

male patient presented with Bannwarth’s syndrome [13]. Thisincludes headache, facial palsy, and radiculopathy, as wellas CSF lymphocytosis. LB is the vector-transmitted disease,which is sometimes difficult to diagnose, especially whenneurological symptoms are dominant and final diagnosismay cost a lot [5, 14]. Of note is that cranial neuritis ispresented by facial nerve palsy with up to 60% of all Lymeneuroborreliosis patients [1]. Here we presented for the firsttime the emergence of Lyme neuroborreliosis in southernBosnia and Herzegovina. Several studies previously showedthe presence of LB in the surrounding areas, mostly innorthern Croatia and Serbia, but none of them reported theincidence of the disease in southern Bosnia and Herzegovina[9–12]. Thus, LB represents a growing public health threat inthe world [3, 8]. Recent molecular and genetic studies haveconfirmed that B. burgdorferi, the spirochetal agent of LB, isone of the most complex bacteria known [15]. This shouldalert all physicians to take into account the presence of Lymeneuroborreliosis in southern Bosnia and Herzegovina as anew problem for epidemiologists and other physicians.Thus,they should put more effort to recognize LB on time andproperly treat it.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgments

The authors thank Dr. Maja Arapovic and Miss Ani Gerbinfor critical reading of the paper. Dr. Jurica Arapovic issupported by the Federal Ministry of Education and Science,Bosnia and Herzegovina, FMON 2010.

References

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[3] N. Rudenko, M. Golovchenko, L. Grubhoffer, and J. H. Oliver,“Updates on borrelia burgdorferi sensu lato complex withrespect to public health,” Ticks and Tick-Borne Diseases, vol. 2,no. 3, pp. 123–128, 2011.

[4] T. J. Kowalski, S. Tata, W. Berth, M. A. Mathiason, and W. A.Agger, “Antibiotic treatment duration and long-term outcomesof patients with early lyme disease from a lyme disease-hyperendemic area,” Clinical Infectious Diseases, vol. 50, no. 4,pp. 512–520, 2010.

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[6] I. S. Smith and D. P. Rechlin, “Delayed diagnosis of neurobor-reliosis presenting as bell palsy and meningitis,” Journal of theAmerican Osteopathic Association, vol. 110, no. 8, pp. 441–444,2010.

Case Reports in Infectious Diseases 3

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[8] Z. Hubalek, “Epidemiology of lyme borreliosis,” Current Prob-lems in Dermatology, vol. 37, pp. 31–50, 2009.

[9] S. Dautovic-Krkic, S. Cavaljuga, M. Ferhatovic et al., “Lymeborreliosis in Bosnia andHerzegovina—clinical, laboratory andepidemiological research,” Medicinski Arhiv, vol. 62, no. 2, pp.107–110, 2008.

[10] D. Dordevic, R. Dmitrovic, V. Derkovic et al., “Lyme disease inYugoslavia,” Vojnosanitetski Pregled, vol. 47, no. 4, pp. 249–253,1990.

[11] M. Hukic, F. Numanovic, M. Sisirak et al., “Surveillance ofwildlife zoonotic diseases in the Balkans Region,” MedicinskiGlasnik (Zenica), vol. 7, no. 2, pp. 96–105, 2010.

[12] R. Mulic, S. Antonijevic, Z. Klismanic, D. Ropac, and O. Lucev,“Epidemiological characteristics and clinical manifestations oflyme borreliosis in Croatia,” Military Medicine, vol. 171, no. 11,pp. 1105–1109, 2006.

[13] A. Bannwarth, “Zur Klinik und Pathogenese der “chronischenlymphocytaren Meningitis”—I. Mitteilung,” Archiv fur Psychia-trie und Nervenkrankheiten, vol. 117, no. 1, pp. 161–185, 1944.

[14] L. Johnson, A. Aylward, and R. B. Stricker, “Healthcare accessand burden of care for patientswith Lymedisease: a largeUnitedStates survey,” Health Policy, vol. 102, no. 1, pp. 64–71, 2011.

[15] R. B. Stricker, A. Lautin, and J. J. Burrascano, “Lyme disease: thequest for magic bullets,” Chemotherapy, vol. 52, no. 2, pp. 53–59,2006.

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Case Report The First Evidence of Lyme Neuroborreliosis in …downloads.hindawi.com/journals/criid/2014/231969.pdf · Case Report The First Evidence of Lyme Neuroborreliosis in Southern